HomeMy WebLinkAbout020-1136-30-000
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AS BUILT SANITARY SYSTEM REPORT
OWNER ~Oit'1 /f4A-) ffp!>A~ Jr3/0
ADDRE S ! y'~~~ y ~E Lc> AGCY
vpSr~,.~ Cl,! S . ..S,/O/ 60
SUBDIVISION / CSM# ICIP6E LOT (o T
SECTION. T 2-1 N-R -r W, Town of
VOSO
$
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICA 9 H ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
a cip,~ Ct~ - / G O d '
ic T
BENCHMARK'
~lsE laps D~ Z _5;E~71c 1 5
ALTERNATE BM:
S //V W"., %o/rt') SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
CLO _ W 1ES&-R :;T-,
Manufacturer: N£w " -'E C's -Liguid Capacity: Foo
Setback from: Well House►-'ew- 22' Other
Pump: Manufacturer /V+ Model# Size
Float seperation Gallons/cycle:
Alarm Location
~A -:SOIL ABSORPTION SYSTEM TiPe,vG Ads
Width' Length 7 Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: gZ~ House 3 Other
F~~srl~~ cov2 = y9 37
ELEVATIONS
F~rsr,,~~ 'Z
Building Sewer ST Inlet. S' 7S ST outlet
PC inlet / PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade ~F5, 0 Final grade ~S o /a v Tit'E~~G`
"^a ~ t f } ' ' t NEW eD O
$,:~y q SS ~C
DATE OF INSTALLATION: PLUMBER ON JOB: 140MESITE SEPTIC PLUMBING CO 2 Al NUS -
665 O'NEIL RD., HUDSON, WIS. 54016 VDU y O?
LICENSE NUMBER: ROBERT ULBRIGHT
EMPLU 307 M.P.R.S. '
tienif.
INSPECTOR: t*rTALLER $ DESIGNER LIC. 140- 00663 3 / 9 3 : j t ~~iy ~/E~S~I,✓ pUTGE% / J . 6P
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L 'AW0 iusag. 29.19.67kIVATE SEWAGE SYSTEM County:
L nd Human Relations INSPECTION REPORT
S ty and Buildings Division
' (ATTACH TO PERMIT) sanitar rtni
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village i Town of: State P THOMAS - BRA v.: nsp. M ev.: CWescripIWOSON Parcel Tax No.:
t -20-1 1 36"' 100
TANK INFORMATION ELEVATION DATA A9300233
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss --ead 7iL
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manu acturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type-Of CHAMBER Moe Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing _ I i
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 20.29.19.673
I
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. I 1-H
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
-1111 SANITARY PERMIT APPLICATION
T OILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY X
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 /
8%)t 11 inches in size. Chec i re Sion to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER / PROPERTY LOCATION
-ro-s t j ,.A,, /UW Y. A/WY., s ZO T Z~ N, R E (o W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
Q t1lill lei
CITY, STATE ~ / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
tSot~ Ll,• S'yA~lo 3~v Sd~G ~r,~
CITY NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE : 11f SD,tJ ~E- vl~W
❑ Publics , 1 or 2 Fam. Dwelling of bedrooms PARCEL TAX M ( )
III. BUILDING USE: (If building type is public, check all that apply) d Z Q " 1136- ij 0
1 El Apt/Condo
2 ❑ Asssmbly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. LJ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 [kileepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit 2, Pressure ~L r 43 ❑ Vault Privy
14 ❑ System-In-Fill ~~~~~~1ff 2. 7Z6t 444_ ~1~GGT !j X lp
VI. ABSORPTION SYSTEM INFORMATION: ~z • S 9G -5-
1.GALLONS PER DAY 2. ABSORP. AREA 3. ABSOrP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) Min./inch) g ELEVATION
Feet 757 v Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank IYA90 Z
L•
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) *P/MPRSW No. Business Phone Number:
/2046E7- 211Aelei7T 3307 7/5 ~C~
Plumber's Address (Street, City, State, Zip Code)-
&95 a' 'VelZ f fvl~no .v Lv! S <5 yor
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved $ggry PerFee (Includes Groundwater Date Issue Issuing A ent Si re (N tamps
Surcharge Fee)
roved d ❑ Owner Given Initial D
Fpp
Adverse Do I ~ ~~00
t rmination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiralion date, and at the time of renewal any new
criteria ;n the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit musi be approved by the. permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary P--rrr°t Transfer/Renewal Form (SEE) 63199) to be
submitted to the county prior to installation.
5. Onsrte, sc•wje Systems must be proper ,'y maintained. rh tank(s) must be pur , ~;j
ra a I censed
pumper whenevpr necessary, usually every 2 to years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
If. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on systeni type.
VI. Absorpftn system information. Provide all information requested in #f" 7
VIL Tank infor ration. Fill in the , pa, ty of every new a n,.':, f x r r !ank. t~,e °c fal gallon: mjmLer of
tanks an_' r,anufacturer's nary+e. indicate prefab or site i,~ E,.;tvd aro it+,ik -ii-tierial. Gom,,'ete ~'or all
septic, pump/siphon and hok-llir:g tanks for this system. Check e,z- imt ,i,tl approval only if tanks received
experimerRrai product approval frc;-n DILHR.
Vill. Responsibility statement. lnstaiiir,ct plumber is-to fill-in-nanse se number with appropri,,i!e prefix (e.g.
MP, etc.), address and phone nuo,.bi,r. Plumber must sign , r :.Ton form.
IX. County/Department Use Oniv
X. Ccunty/!department Use On,y. ,
Corr, , l:.nf~ ar,d =.t cc f . „?,rs not smaller th;~r~ I! inct >ubmitlpd f _ t~,r. u-ity. The
plans r,'i:zA i dude thu, f g. plot p'an, 1f sus iv .
C:y1F r .n t: r r r, ,-tiOn of
FIJ1 i,x ni Septii;. i!,ner tre~Rtme^.t larks: 6,;0dlnt7 w0m-;Nate tl~i:e'' service;
StY4±dS-ti r i~ike5, pumet r:( --hr,n tanks; distilhubor! boxes ~,Q,i 6, ;n
~ySTE!CYi~, f N~~ ±:_e 1r~gfit system
areas; acid the location of it;e served, D) hoiizontai a • ,.r`.~~ a:?I ~r t:i~n rE,,f->rEiC^(- t`-In.t,;
C) complete spec fications for pur;ps and controls; dose voiume; elevatot; ci,ffe ences; friction loss; pump
performance curve; pump model and pump manufa(.turer; D) cross section of the so l absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410inc:l!zded the c,traation Of surcharges (fees) for r n" r (11
reg„I t~d practices whit" ::,n affect groundwater.
The nionies collected thre e,' Hic-e surcharge, ar(- used t:: tclniat +c. n i-
water contamination invesfirgatinns and establishment of l r
SBD-6398 (R.11/88)
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F I n a i Grade 7xif~Pz:-
4" CQ$i Iron
3l A t:►o re Pipe
Vent 'Pipe'
E -7 .rinni Grade
1
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~!.*r~Nath Pipa f Coupling TerrnlnGlIng At
0
Bottom Of ystam
14 V
rt Go Lv 7~p _Aj c f "
Fresh Air Inlets And Observation Pipe
Approved Vint Cap
Minimum 1211 Above
Final Grade
Af ~~~n
' 30 "Above Pipe
ven. Pipe
"to Flnai Grade
Synthetic Covle
min. 2" AggrOver Pipe
DistrIbufion - Tee
Pip+
0 0 0 A99f e9aPerforated Pipe Below
Beneath Pi"'- Coupling Terminating At
Now-
ottom of System
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1I wonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page -I- of 3
Labor and Human Relations
Division of Safety 6 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
sr, c rzoi'~
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
71-~qNI GOVT. LOT NW 1/4 IVV 114,S2.D T Z 9 N,R I E ( 7:
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK SUED. NAME OR CSM #
ql/ 1/,i//E C,Y ~v,%/ow ,P~' E 2-►~ ~oDi7-.
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE DOWN NEAREST ROAD f
I-FUOS0.u 4JIS 5ya/(o (715)3P~-53/0 171 ~vso,v !/gi~Ey
(j New Construction Use ( Residential / Number of bedrooms DE't/ [ J Addition to existing !wilding
Vj Replacement ( j Public or commercial describe
Code derived daily flow oa gpd 16 & Recommended design loading rate I--- bed, gpd/ft2 • trend!, gpd&2
Absorption area required bed, ft2 -750 trench, ft2 Maximum design loading rate bed, gpd/ft2 00 trench, gpd/ft2
Recommended infiltration surface elevation(s) Se-e P!~z - 3 ft (as referred to site plan benchmark)
Additional design / site considerations 7~tS6 w ~,~54 E s w/ DAP I /9 o k
Parent material 5G5 Sg 3 vR~ ti ^,C~O T - 7~~rr~ z7 Flood plain elevation, if applicable ti ft
s
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TM
U= Unsuitable fors stem ®S ❑ U ZIS ❑ U PS ❑ U WS ❑ U QS ❑ U ❑ S QU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourtd3y Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Iendh
O- /Y /O ie 2/2_ Si/ Z, 4-" jle /I'. 7f/• ex .2- -F N N
0 P, 1y- to /o y 3 S// /,f, sd,< e S- If - Y s
Ground /3s S1 1,f 5,6 k n~`f l2 e $ - . S
tL c io /o ,e s s o, 4-%, s , 7
Depth to !
„ So//s -(oh at yo s s r te/ 93 0 `
Rio c-d9 Co-y~oli T - S/~'l" ~ C ~ E - '~~t f>
Remarks: 9DJif~F~c9T %o•ri sTi~~ s`STc~-y -
Boring # 2f
"/2 /O /f i 2 SW Z slr,~ v-M es,
~Z Goo s y ~s , e,
Ground
s c, s •P
41 yU ft. C o /aye J-1141
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
T0,(3~~T ~1~13~1'ch7' 715= 3P6 -60
Address: SS 0 ' lu /L ;ii~P• #VPSo.J 4)/ Syo/ 'I ~f - f 3 CSTrl zVf
Signature: Date: CST Number:
~CJlit / C~Gt>Q
I'INAL
PROPERTY OWNER S 4"v1740 v 2 SOIL D E S C TION REPORT Page Zol 3
PARGELI.D.8 `ot G y ly/~~DW /~,J~CrE'.
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Gp -2
in. Munsell Qu. Sz. Cont Color Gr. Sz: h. Bed ranch
3 lpC: a 0 D
/3z 0- 51 2
Ground /-0 y 5 -S
Depth to
limiting
factor
Remarks:
Boring #
i
l
13
i
Ground
elev.
ft.
Depth to i
limiting F
factor
Remarks:
Boring #
i
Ground
elev.
ft
Depth to
limiting
tam =
Remarks:
Boring #
i
i
Ground
elev.
It.
Depth to
limiting
factor
Remarks:
con aq'IM0 ncenrn
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C6 4), 01,
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the -raI 510541A/17'~) OR residence located at:
114, /v 1/4, Sec. 2-49 , T:~f N, R /1 W, Town of
Upon Inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly. c
Last time serviced_ 3
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity: /
Construction: Prefab Concrete Steel Other
Manufacurer (if known) : j~tjh~yC-s
Age of Tank (if known) :
r I.CV4,
, WYC14 Z" - - RoREP 7
(Signature) (Name) Please Print
/o4 5 330 A%/CS I ~O
(Title)C~ G (License Number)
(Date)
Farm to be completed by licensed plumber (x.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR-83, Wis. Adm. Code (except for
inspection opening over outlet baffle)`.
Name 'rgo aep 2llh1e C4 Signature / ---4-P/MPRS 3~o
5/88
S T C - 105
01
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
~r
OWNER/BUYER
ADDRESS W/4 Ac y 1//Z~_ /V FIRE NUMBE
CITY/STATE t5 ZIP
PROPERTY LOCATION:1/4,NW 1/4, SECTION ~ , T-?:Y__N-Rff-W
TOWN OF v ,~O''" St. Croix County,
SUBDIVISION G~~ll~w R(f} - z
LOT NUMBER_6!~
Improper use and maintenance of your septic system could
result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three
years or sooner, if needed by a licensed septic tank pumper. What
you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system. .
St. Croix County residents may be eligible to receive a grant
for a maximum of 60% of the cost of replacement of a failing
system, which was in operation prior to July 1, 1978. St. Croix
County accepted this program in August of 1980, with the
requirement that owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix Zoning a
certification form, signed by the owner and by a mater plumber, ,
journeyman restricted plumber, plumber or a licensed pumper
verifying that (1) the on-site wastewater disposal system is in
proper operating condition and (2) after inspection and pumping (if
necessary),
the sept
is tank is less than 1/3 full of
sludge
scum. and
I/We, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix Co. Zoning Officer within
30 days of the three year expiration
Y date.
SIGNED: l r ~J Ll~i~, lyn
DATE : t)~~ir~ [lam. I,, j 213
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
I i
STC-100.
.This application form is to be completed in full and signed by
the owner(s) of the property being developed. Any inadequacies
will only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(spec
house), thenia second form should be retained and completed when
the property' is sold and submitted to this office with the
appropriate deed recording.
owner of property / /~Alu ,~Y/g /ti U2
Location of * property PW 1/4 4114d
1/4, Section 2,0 , T-fL_N-R_LLW
Township
Mailing address
Address of site
d9 V
4P /
Subdivision name w~~ll~Ctr/~G~" _ 2 of no. !7 "
other homes on property? -yes No
Previous owner of property~0 LvE~7-E/S~~.cJ
Total size of parcel
Date parcel-was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)?_Yr_s x No
SVolume and Page Number = as recorded with t
of Deeds. he Register
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owners of
the property described in this information form
b v
Y virtue of a
warranty deed recorded in ,
the office of the County Register of
Deeds as Document No.-i-7/7/3 and that ~ I (we)
the ) presently
own proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No.
Signature ofla6_pllicant Co-applicant
Date f Si nature Da of S
i nat
g
!
i
1
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1882 THIS ae^" NESERVED FOR RECORJINO CAT^
WARRANTY rDEED
391713 ) VOL l/t )ti PAS,E
A. R. Bertelsen aka RbIG1fi7lE.S Of-tICE
This Deed, made between
9T. CROiX CO., 7V16.
Arnold R.,-"Rertelsen and Virginia A. Berteis~n~
Ret'd for Record this 9th
-
Grantor, day of Mar A.0. 1984
Thomas D. Spa~n}iour and Francespainhour, Ot 11:30 A
and........
husband and wife as joint tenants.
. . JI ~--V
.
Grantee, ~YIM •
Witnesseth, That the said Grantor, for a valuable consideration......
~I
conveys to Grantee the following described real estate in St . C roix RETURN TO
First Financial S & L
County, State of Wisconsin: 130 S. Barstow St.
Eau- Claire:_41I._547Q1_
Tax Parcel No:
t TR32.1 0
FEE
Lot 64, Willow Ridge Second Addition to the town of Hudson
subject to recorded easements and covenants.
I
j
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And--- - -
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same.
Dated this 2nd day of March . ------.19..84...
-------..-(SEAL) / ----..-.(SEAL)
A. R. Bertelsen
. -
-_-(SEAL) .....(SEAL)
. Virginia A. Bertelsen
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
St. Croix ss.
------------County.
authenticated this day of......._... 19...... Personally came before me this day of
=March 19._84 _ the above named
A. R. Bertelsen and Virginia A. Bertelsen
" •
TITLE: MEMBER STATE BAR OF WISCONSIN
~ru~uunrrr,
(If not.
authorized by A 706.06, Wis. Stats.) s
J, j nown to be the person who executed the
w: YA fbtci instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY o l R Y-•En P. P ie ld
Arnold R.. Bertelsen,
.
Real Estate Rroker `l- .
St, oix
.........._...-....r`f- \otn Public __-.County, Wis.
(Si,:Z1 Urf•s may he authenticated or acknowled;;edlBnt}i ~In" Commission is permanent. (If not, state expiration
are not rweessary.) 'date: - February 10 t._ 1385._
•Nsm?a nC pe-- ;zn;nq in any -;)wity sh,,,.u'.I 'n• tyV^I ;•ri~-b•~1 1...1.•.c .h. ir -i¢rst.l ra^•.
WARRANTY DEED STATE. HiR OF WISCONSIN 1Ci ~--in 1-.1 Blank Co. Tne.
FORM No. 1 - 19,Z M.;-,kee, Wis.
~ y ~lS
~ti I ~ ZS
Q.311
i
AS BUILT SANITARY SYSTEM REPORT
sn G~
OWNER ~C TOWNSHIP (J-t~ SEC.Z~IN - R I W
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISIO OT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
.01
I di at N r h rr w
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: WOO
Number of rings on cover : Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle gallons; Total capacity of
distribution lines gallon: size of pump head;
gallon per minute horsepower ;brand name of pump
and model number ;
Type of warning•device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE; Number of pits feet diameter
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines width length tile depth
SEEPAGE TRENCH: width a E length 1
PERCOLATION RATE AREA REQUIRED AREA AS BUILT
< INSPECTOR l
DATED PLUMBER ON JOB
LICENSE NUMBER
DEP.j RTMEI6T OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.'BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
IIf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: DDRESS OF PERMIT HOLDER: INSPECTION
Arnold Bertelsen 7St . Croix Heights, Hudson, WI i1"3-3F-'? j''~
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: Town o t Hudson R F. PT. E EV.: CST REF. PT. ELEV.:
NW NW, Sec. 20, 129N-R19W, Lot 64, Willow Ridge II
Name of Plumber: MP/MPRSW No.. County: Sanitary Permit Number:
Richard Hopkins I1059 St. Croix 38480
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY- TANK INLET ELE V.. TANK OUTLET ELEV.: WARN G LABEL ILOCKIN CO )(E
0 V P DED: PROVI
8.~ YES ❑ O NO
BEDDING: VENT DIA.:I f VENT ATL. WATE R NUMBER OF ROAD: PROPERTY WEL BUILDI G: V NT O FRESH
ALI~H MFEET FROM LIN gyp IR INLET❑YES ❑NO YES ❑NO NEAREST t(„~ V//V/
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PR OFERTV IV, ELL- BUILDING. IVEN ARN OTRESH
(DIFFERENCE BETWEEN FEET FROM LINE.
PUMP ON AND OFF) ❑YES ❑NO NEAREST 30 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing jL1111,TH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LE IND TREOOF IDISTR PIPE S?CING Co Y~L INSIDE DIA.: P
PIT PTFI
DIMENSIONS
GHAVEL ULPTH FILL DE H DIST PI F DISTR PIPE DISTR. PIPE TER IA L: NO. D NUMBER OF PROPERTY WEL BUILDING. VENT TO RES
BELOW PIPES. - A~dVE'CQO'ER. ELEV. LET E V N PIPE FEET FROM
7
< 2 7 Z / NET
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the text of the fill material r PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound syst s make certain at ON REVERSE SIDE. SHOW ELEVA-
meets the eria or medium San NS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE ER NEN RK S: OBSERVATION WELLS.
❑YE ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED TV SOIL. S DED SEEDED. MULCHED.
CENTER. EDGES.
YES N ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAY rDTELO PF- FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MAN .OLD TERIAL: NO. DI R. TR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.. ELEV.. DIA.. ELEV.: PIPE DIA.:
ELEVATION AND
DISTRIBUTION
HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER A RIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS:
❑YES ❑N ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OB R TIO w s: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
7. ❑YES ❑NO ❑YES ❑NO NEA - 11
10 V55 ~C~ti Yi
9 s ~ S~5
~.7o
Sketch System on tain county file for audit
Reverse Side.
SIGNAT ^ [ITLE: 77/
DILHR SBD 6710 (R. 01/82) /
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wn the of p~ ~rt4e Q f ) then th's f
bArOAO VS. hay otii~erorti er p r o p e ~.1' 1 ` Yt /
seor 00 ra (S a
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tefo tenrtyaaeea Ofthep toth y [ j -rp.
he se u e~or U.0 he bas 4 the sa/sys , a ff/cbed,n t vr/ } ,f 1\ , w'.w_ 1,~;~
tee the of h/s t~
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DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INdUSTRi0, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Propert Owner: Mailin Address:
r
Property Loca .on: ~6i#+frll+Fhgo.or Township: County: 7- -
l~f % %s P /T NCR (or) W /
Lot Number: 1BIkNo.: Subdivision Na . Neares Road, ake or Landmark: State Plan I.D. Number:
4 ~ (If assigned) -47
TYPE OF BUILDING ~•t'
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedroom
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION ME4T (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public .7D G
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name Plumber: Sign re: RAP'/MPRSW No.: Phone Number:
GW O ~I'6 SY~
a j-
~ r1 S w
Plumber's Addr s: Name of Designer.
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing A nt: Fe Oa Date: Sanitary Permit Num ber:
dp APPROVED 3 QQ QQ
1(la-46 ❑ DISAPPROVED
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
DEPARTMENT OF REPORT ON SOUBORINGS AND SAFETY & BUILDINGS
DIVISION
INDUSTRY,+. ' P.O. BOX 76
LABOR AND - PERCOLATION TESTS (115) MADISON Wi53707
HUMAN RELATIONS (H63.090) & Chapter 145.045)
LOCATION: SECTION: OWNSHIP/M1~+6+RAJI : LOT NO.: BLK. NO.: SUBDIVISION NAME:
N~ /a/"
u1/a o /T/td/R19~ (or u 4so"i
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: /
C D /'x ►"/~Ld Sf? S 7C Gi S A~rC Sa t s r G7
USE DATES OBSERVA ONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROF:I E DESCRIPTIONS: ER A"f10N TESTS:
Residence New ❑Replace 1 /
02-
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-I -FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
N S D U 9S ❑U ®S ❑U EIS ®U 0 S ZU Ca,vQ A~OA-0101 Bell
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: x///4 Floodplain indicate Floodplbir elevation:
PR FILE DESCRIPTIONS
BORING TOTAL/ DEPTH TO GROUNDWATE!14N CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH+fd. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- l -7 ~.S• . O6I 1. 3,6
„ f3 s/~ S
B :S4 6 . e, v 94 -5
,S
B- 3 to C) I Aa u e- S •
7 s' 3, s
Z t(
13-
B-
PERCOLATION TESTS
TEST DEPTH' WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCHES
NUMBER l-P1CkkE& AFTER SWELLING INTERVAL-MIN. -PERIOD 1 PE SOD 2 P / G~
P_ / y. 3' 3 W
P_ s
P- 3 ~a s 3 3
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION le 6 4,-
I -
i i 3 i+- ( !r'~1,-- 7-
1 0 q Q~. t - I I
I I ~ ~ Per 7r'ec t+
l t
~ I i
Pa F . -r ! i
I
f ~
I X03' - I i 3Z b-
I
I
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
-ew r ' ~e 1 rz -F-3
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
r P. l So ~r. U!b
CST aSIGATURE.
r
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. I
DILHR-SBD-6395 (R. 02/82) - OVER -